CHEYENNE COUNTY HOSPITAL & HEALTH CENTER FOUNDATION: Form 990, tax year 2021

View the entire original 990 at ProPublica ↗

Organization
CHEYENNE COUNTY HOSPITAL & HEALTH CENTER FOUNDATION (EIN 47-0686476)
Tax period
2021-01-01 to 2021-12-31
Filed
2022-11-08
IRS object ID
202243129349304149
Schema version
2021v4.2
Source
Download XML · Original 990 at ProPublica

Every field in the e-filed return. Faint text is the IRS element name, for citing.

Return header ReturnHeader

FieldValueIRS element (for citing)
Return2022-11-08T15:37:22-06:00ReturnTs
Tax Period End2021-12-31TaxPeriodEndDt

Preparer Firm PreparerFirmGrp

FieldValueIRS element (for citing)
Preparer Firm EIN450250958PreparerFirmEIN

Preparer Firm Name PreparerFirmName

FieldValueIRS element (for citing)
Business Name Line1EIDE BAILLY LLPBusinessNameLine1Txt

Preparer US Address PreparerUSAddress

FieldValueIRS element (for citing)
Address Line118081 BURT ST STE 200AddressLine1Txt
CityOMAHACityNm
State AbbreviationNEStateAbbreviationCd
ZIP680224722ZIPCd
FieldValueIRS element (for citing)
Return Type990ReturnTypeCd
Tax Period Begin2021-01-01TaxPeriodBeginDt

Filer Filer

FieldValueIRS element (for citing)
EIN470686476EIN

Business Name BusinessName

FieldValueIRS element (for citing)
Business Name Line1CHEYENNE COUNTY HOSPITAL & HEALTHBusinessNameLine1Txt
Business Name Line2CARE FOUNDATIONBusinessNameLine2Txt
FieldValueIRS element (for citing)
Business Name ControlCHEYBusinessNameControlTxt
Phone3082545825PhoneNum

US Address USAddress

FieldValueIRS element (for citing)
Address Line11000 POLE CREEK CROSSINGAddressLine1Txt
CitySIDNEYCityNm
State AbbreviationNEStateAbbreviationCd
ZIP69162ZIPCd

Business Officer BusinessOfficerGrp

FieldValueIRS element (for citing)
PersonKELLY UTLEYPersonNm
Person TitleCFOPersonTitleTxt
Phone3082545825PhoneNum
Signature2022-11-07SignatureDt
Discuss With Paid PreparerYes (1)DiscussWithPaidPreparerInd

Signing Officer SigningOfficerGrp

Person Full Name PersonFullName

FieldValueIRS element (for citing)
Person FirstKELLYPersonFirstNm
Person LastUTLEYPersonLastNm
FieldValueIRS element (for citing)
SSN999009999SSN

Preparer Person PreparerPersonGrp

FieldValueIRS element (for citing)
Preparer PersonMEGAN L KOZIOL CPAPreparerPersonNm
PTINP01544037PTIN
Phone4023302660PhoneNum
Preparation2022-11-07PreparationDt

Additional Filer Information AdditionalFilerInformation

Trusted Customer TrustedCustomerGrp

FieldValueIRS element (for citing)
Trusted Customer3TrustedCustomerCd
Authentication Assurance LevelAAL1AuthenticationAssuranceLevelCd
Identity Assurance LevelIAL1IdentityAssuranceLevelCd
FieldValueIRS element (for citing)
Tax2021TaxYr
Build TS2022-09-23 18:48:47ZBuildTS

Form 990 IRS990

FieldValueIRS element (for citing)
Principal OfficerKELLY UTLEYPrincipalOfficerNm

US Address USAddress

FieldValueIRS element (for citing)
Address Line11000 POLE CREEK CROSSINGAddressLine1Txt
CitySIDNEYCityNm
State AbbreviationNEStateAbbreviationCd
ZIP69162ZIPCd
FieldValueIRS element (for citing)
Gross Receipts$97,761GrossReceiptsAmt
Group Return For Affiliates0GroupReturnForAffiliatesInd
Organization501c3Yes (X)Organization501c3Ind
Website AddressWWW.SIDNEYRMC.COMWebsiteAddressTxt
Type Of Organization CorpYes (X)TypeOfOrganizationCorpInd
Formation1985FormationYr
Legal Domicile StateNELegalDomicileStateCd
Activity Or MissionHEALTH CENTER FOUNDATION SUPPORTS SIDNEY REGIONAL MEDICAL CENTER IN THEIR QUEST TO PROVIDE THE MOST UP-TO-DATE FACILITIES, EQUIPMENT AND SERVICES. THROUGH OUR RESPONSIBLE DONATION MANAGEMENT, WE ARE HELPING TO ASSURE THAT OUR COMMUNITY WILL CONTINUE TO HAVE LOCAL, QUALITY HEALTH CARE AND CURRENT STATE-OF-THE-ART TECHNOLOGIES, IN A FACILITY MAINTAINED AND UPDATED TO MEET THE EMERGING AND GROWING NEEDS OF CHEYENNE COUNTY AND THE SURROUNDING REGIONS.ActivityOrMissionDesc
Voting Members Governing Body11VotingMembersGoverningBodyCnt
Voting Members Independent11VotingMembersIndependentCnt
Total Employee0TotalEmployeeCnt
Total Volunteers11TotalVolunteersCnt
Total Gross UBI$0TotalGrossUBIAmt
Net Unrelated Bus Txbl Incm$0NetUnrelatedBusTxblIncmAmt
PY Contributions Grants$18,457PYContributionsGrantsAmt
CY Contributions Grants$45,312CYContributionsGrantsAmt
PY Program Service Revenue$0PYProgramServiceRevenueAmt
CY Program Service Revenue$0CYProgramServiceRevenueAmt
PY Investment Income$19,591PYInvestmentIncomeAmt
CY Investment Income$48,886CYInvestmentIncomeAmt
PY Other Revenue$0PYOtherRevenueAmt
CY Other Revenue-$66CYOtherRevenueAmt
PY Total Revenue$38,048PYTotalRevenueAmt
CY Total Revenue$94,132CYTotalRevenueAmt
PY Grants And Similar Paid$11,044PYGrantsAndSimilarPaidAmt
CY Grants And Similar Paid$11,873CYGrantsAndSimilarPaidAmt
PY Benefits Paid To Members$0PYBenefitsPaidToMembersAmt
CY Benefits Paid To Members$0CYBenefitsPaidToMembersAmt
PY Salaries Comp Emp Bnft Paid$0PYSalariesCompEmpBnftPaidAmt
CY Salaries Comp Emp Bnft Paid$0CYSalariesCompEmpBnftPaidAmt
PY Total Prof Fndrsng Expns$0PYTotalProfFndrsngExpnsAmt
CY Total Prof Fndrsng Expns$0CYTotalProfFndrsngExpnsAmt
CY Total Fundraising Expense$17,844CYTotalFundraisingExpenseAmt
PY Other Expenses$16,007PYOtherExpensesAmt
CY Other Expenses$17,844CYOtherExpensesAmt
PY Total Expenses$27,051PYTotalExpensesAmt
CY Total Expenses$29,717CYTotalExpensesAmt
PY Revenues Less Expenses$10,997PYRevenuesLessExpensesAmt
CY Revenues Less Expenses$64,415CYRevenuesLessExpensesAmt
Total Assets BOY$1,737,974TotalAssetsBOYAmt
Total Assets EOY$1,859,641TotalAssetsEOYAmt
Total Liabilities BOY$2,300TotalLiabilitiesBOYAmt
Total Liabilities EOY$0TotalLiabilitiesEOYAmt
Net Assets Or Fund Balances BOY$1,735,674NetAssetsOrFundBalancesBOYAmt
Net Assets Or Fund Balances EOY$1,859,641NetAssetsOrFundBalancesEOYAmt
MissionTO ASSURE THERE IS, AND ALWAYS WILL BE, A STRONG FINANCIAL FOUNDATION SUPPORTING OUR HEALTH CARE COMMUNITY.MissionDesc
Significant New Program Srvc0SignificantNewProgramSrvcInd
Significant Change0SignificantChangeInd
Expense$11,873ExpenseAmt
Grant$11,873GrantAmt
Revenue$0RevenueAmt
DescPROVIDE FUNDING TO SUPPORT SCHOLARSHIPS AND INTERN PROGRAMS FOR INDIVIDUALS CURRENTLY STUDYING IN THE HEALTH CARE FIELD.Desc

Prog Srvc Accom Acty2 ProgSrvcAccomActy2Grp

FieldValueIRS element (for citing)
Expense$0ExpenseAmt
Grant$0GrantAmt
DescPROVIDE SUPPORT TO CHEYENNE COUNTY HOSPITAL ASSOCIATION, D/B/A SIDNEY REGIONAL MEDICAL CENTER, TO FURTHER THEIR QUEST TO PROVIDE THE MOST UP-TO-DATE FACILITIES, EQUIPMENT AND SERVICE.Desc

Prog Srvc Accom Acty3 ProgSrvcAccomActy3Grp

FieldValueIRS element (for citing)
Expense$0ExpenseAmt
Grant$0GrantAmt
DescPROVIDE FUNDING TO ASSIST WITH DENTAL PROCEDURES FOR THOSE IN NEED.Desc
FieldValueIRS element (for citing)
Total Program Service Expenses$11,873TotalProgramServiceExpensesAmt
Described In Section501c3Yes (1)DescribedInSection501c3Ind
Schedule B RequiredYes (1)ScheduleBRequiredInd
Political Campaign Acty0PoliticalCampaignActyInd
Lobbying Activities0LobbyingActivitiesInd
Subject To Proxy Tax0SubjectToProxyTaxInd
Donor Advised Fund0DonorAdvisedFundInd
Conservation Easements0ConservationEasementsInd
Collections Of Art0CollectionsOfArtInd
Credit Counseling0CreditCounselingInd
Donor Rstr Or Quasi Endowments0DonorRstrOrQuasiEndowmentsInd
Report Land Building EquipmentYes (1)ReportLandBuildingEquipmentInd
Report Investments Other Sec0ReportInvestmentsOtherSecInd
Report Program Related Invst0ReportProgramRelatedInvstInd
Report Other Assets0ReportOtherAssetsInd
Report Other Liabilities0ReportOtherLiabilitiesInd
Include FIN48 FootnoteYes (1)IncludeFIN48FootnoteInd
Independent Audit Fincl Stmt0IndependentAuditFinclStmtInd
Consolidated Audit Fincl StmtYes (1)ConsolidatedAuditFinclStmtInd
School Operating0SchoolOperatingInd
Foreign Office0ForeignOfficeInd
Foreign Activities0ForeignActivitiesInd
More Than5000 K To Org0MoreThan5000KToOrgInd
More Than5000 K To Individuals0MoreThan5000KToIndividualsInd
Professional Fundraising0ProfessionalFundraisingInd
Fundraising ActivitiesYes (1)FundraisingActivitiesInd
Gaming Activities0GamingActivitiesInd
Operate Hospital0OperateHospitalInd
Grants To Organizations0GrantsToOrganizationsInd
Grants To IndividualsYes (1)GrantsToIndividualsInd
Schedule J RequiredYes (1)ScheduleJRequiredInd
Tax Exempt Bonds0TaxExemptBondsInd
Engaged In Excess Benefit Trans0EngagedInExcessBenefitTransInd
PY Excess Benefit Trans0PYExcessBenefitTransInd
Loan Outstanding0LoanOutstandingInd
Grant To Related Person0GrantToRelatedPersonInd
Business Rln With Org Mem0BusinessRlnWithOrgMemInd
Business Rln With Fam Mem0BusinessRlnWithFamMemInd
Business Rln With35 Ctrl Ent0BusinessRlnWith35CtrlEntInd
Deductible Non Cash Contri0DeductibleNonCashContriInd
Deductible Art Contribution0DeductibleArtContributionInd
Terminate Operations0TerminateOperationsInd
Partial Liquidation0PartialLiquidationInd
Disregarded Entity0DisregardedEntityInd
Related EntityYes (1)RelatedEntityInd
Related Organization Ctrl Ent0RelatedOrganizationCtrlEntInd
Trnsfr Exmpt Non Chrtbl Rltd Org0TrnsfrExmptNonChrtblRltdOrgInd
Activities Conducted Prtshp0ActivitiesConductedPrtshpInd
Schedule O RequiredYes (1)ScheduleORequiredInd
IRP Document0IRPDocumentCnt
IRP Document W2 G0IRPDocumentW2GCnt
Employee0EmployeeCnt
Unrelated Bus Incm Over Limit0UnrelatedBusIncmOverLimitInd
Foreign Financial Account0ForeignFinancialAccountInd
Prohibited Tax Shelter Trans0ProhibitedTaxShelterTransInd
Taxable Party Notification0TaxablePartyNotificationInd
Nondeductible Contributions0NondeductibleContributionsInd
Quid Pro Quo ContributionsYes (1)QuidProQuoContributionsInd
Quid Pro Quo Contri DisclYes (1)QuidProQuoContriDisclInd
Form8282 Property Disposed Of0Form8282PropertyDisposedOfInd
Rcv Fnds To Pay Prsnl Bnft Cntrct0RcvFndsToPayPrsnlBnftCntrctInd
Pay Premiums Prsnl Bnft Cntrct0PayPremiumsPrsnlBnftCntrctInd
Indoor Tanning Services0IndoorTanningServicesInd
Subj To Tax Rmnrtn Ex Prcht Pymt0SubjToTaxRmnrtnExPrchtPymtInd
Subject To Excs Tax Net Invst Inc0SubjectToExcsTaxNetInvstIncInd
Info In Schedule O Part VIYes (X)InfoInScheduleOPartVIInd
Governing Body Voting Members11GoverningBodyVotingMembersCnt
Independent Voting Member11IndependentVotingMemberCnt
Family Or Business Rln0FamilyOrBusinessRlnInd
Delegation Of Mgmt Duties0DelegationOfMgmtDutiesInd
Change To Org Documents0ChangeToOrgDocumentsInd
Material Diversion Or Misuse0MaterialDiversionOrMisuseInd
Members Or Stockholders0MembersOrStockholdersInd
Election Of Board Members0ElectionOfBoardMembersInd
Decisions Subject To Approva0DecisionsSubjectToApprovaInd
Minutes Of Governing BodyYes (1)MinutesOfGoverningBodyInd
Minutes Of CommitteesYes (1)MinutesOfCommitteesInd
Officer Mailing Address0OfficerMailingAddressInd
Local Chapters0LocalChaptersInd
Form990 Provided To Gvrn BodyYes (1)Form990ProvidedToGvrnBodyInd
Conflict Of Interest PolicyYes (1)ConflictOfInterestPolicyInd
Annual Disclosure Covered PrsnYes (1)AnnualDisclosureCoveredPrsnInd
Regular Monitoring EnfrcYes (1)RegularMonitoringEnfrcInd
Whistleblower PolicyYes (1)WhistleblowerPolicyInd
Document Retention PolicyYes (1)DocumentRetentionPolicyInd
Compensation Process CEO0CompensationProcessCEOInd
Compensation Process Other0CompensationProcessOtherInd
Investment In Joint Venture0InvestmentInJointVentureInd
Upon RequestYes (X)UponRequestInd

Books In Care Of Detail BooksInCareOfDetail

Business Name BusinessName

FieldValueIRS element (for citing)
Business Name Line1KELLY UTLEYBusinessNameLine1Txt
FieldValueIRS element (for citing)
Phone3082545825PhoneNum

US Address USAddress

FieldValueIRS element (for citing)
Address Line11000 POLE CREEK CROSSINGAddressLine1Txt
CitySIDNEYCityNm
State AbbreviationNEStateAbbreviationCd
ZIP69162ZIPCd

Form990 Part VII Section A Form990PartVIISectionAGrp (12 entries)

TitleTitleTxtAverage Hours Per WeekAverageHoursPerWeekRtAverage Hours Per Week Rltd OrgAverageHoursPerWeekRltdOrgRtOfficerOfficerIndReportable Comp From OrgReportableCompFromOrgAmtReportable Comp From Rltd OrgReportableCompFromRltdOrgAmtOther CompensationOtherCompensationAmtIndividual Trustee Or DirectorIndividualTrusteeOrDirectorInd
KELLY UTLEY
EXECUTIVE DIRECTOR1.0039.00Yes (X)$0$203,959$19,470
BILL BUTKUS
PRESIDENT1.000.00Yes (X)$0$0$0Yes (X)
KURT KAISER
VICE PRESIDENT1.000.00Yes (X)$0$0$0Yes (X)
SEAN DOYLE
TREASURER1.000.00Yes (X)$0$0$0Yes (X)
JULIE SHOEMAKER
SECRETARY1.000.00Yes (X)$0$0$0Yes (X)
STAN BELIEU
MEMBER1.004.00$0$0$0Yes (X)
SHERI EHLER
MEMBER1.000.00$0$0$0Yes (X)
VICKIE SMITH
MEMBER1.000.00$0$0$0Yes (X)
NANCI MCCASLIN
MEMBER1.004.00$0$0$0Yes (X)
SHANE COCHRAN
MEMBER1.000.00$0$0$0Yes (X)
DR JAMES POPOVICH
MEMBER1.000.00$0$0$0Yes (X)
NICKY RADCLIFFE
MEMBER1.000.00$0$0$0Yes (X)
FieldValueIRS element (for citing)
Total Reportable Comp From Org$0TotalReportableCompFromOrgAmt
Tot Reportable Comp Rltd Org$203,959TotReportableCompRltdOrgAmt
Total Other Compensation$19,470TotalOtherCompensationAmt
Indiv Rcvd Greater Than100 K0IndivRcvdGreaterThan100KCnt
Former Ofcr Employees Listed0FormerOfcrEmployeesListedInd
Total Comp Greater Than150 KYes (1)TotalCompGreaterThan150KInd
Compensation From Other Srcs0CompensationFromOtherSrcsInd
Cntrct Rcvd Greater Than100 K0CntrctRcvdGreaterThan100KCnt
Fundraising$29,931FundraisingAmt
Related Organizations$5,000RelatedOrganizationsAmt
All Other Contributions$10,381AllOtherContributionsAmt
Total Contributions$45,312TotalContributionsAmt

Investment Income InvestmentIncomeGrp

FieldValueIRS element (for citing)
Total Revenue Column$10,056TotalRevenueColumnAmt
Exclusion$10,056ExclusionAmt

Gross Amount Sales Assets GrossAmountSalesAssetsGrp

FieldValueIRS element (for citing)
Securities$38,830SecuritiesAmt

Less Cost Oth Basis Sales Expnss LessCostOthBasisSalesExpnssGrp

FieldValueIRS element (for citing)
Securities$0SecuritiesAmt

Gain Or Loss GainOrLossGrp

FieldValueIRS element (for citing)
Securities$38,830SecuritiesAmt

Net Gain Or Loss Investments NetGainOrLossInvestmentsGrp

FieldValueIRS element (for citing)
Total Revenue Column$38,830TotalRevenueColumnAmt
Exclusion$38,830ExclusionAmt
FieldValueIRS element (for citing)
Fundraising Gross Income$3,563FundraisingGrossIncomeAmt
Contri Rpt Fundraising Event$29,931ContriRptFundraisingEventAmt
Fundraising Direct Expenses$3,629FundraisingDirectExpensesAmt

Net Incm From Fundraising Evt NetIncmFromFundraisingEvtGrp

FieldValueIRS element (for citing)
Total Revenue Column-$66TotalRevenueColumnAmt
Exclusion-$66ExclusionAmt

Total Revenue TotalRevenueGrp

FieldValueIRS element (for citing)
Total Revenue Column$94,132TotalRevenueColumnAmt
Related Or Exempt Func Income$0RelatedOrExemptFuncIncomeAmt
Unrelated Business Revenue$0UnrelatedBusinessRevenueAmt
Exclusion$48,820ExclusionAmt

Grants To Domestic Individuals GrantsToDomesticIndividualsGrp

FieldValueIRS element (for citing)
Total$11,873TotalAmt
Program Services$11,873ProgramServicesAmt

Fees For Services Accounting FeesForServicesAccountingGrp

FieldValueIRS element (for citing)
Total$2,400TotalAmt
Fundraising$2,400FundraisingAmt

Occupancy OccupancyGrp

FieldValueIRS element (for citing)
Total$3,959TotalAmt
Fundraising$3,959FundraisingAmt

Conferences Meetings ConferencesMeetingsGrp

FieldValueIRS element (for citing)
Total$709TotalAmt
Fundraising$709FundraisingAmt

Depreciation Depletion DepreciationDepletionGrp

FieldValueIRS element (for citing)
Total$3,008TotalAmt
Fundraising$3,008FundraisingAmt

Other Expenses OtherExpensesGrp

FieldValueIRS element (for citing)
DescMISCELLANEOUS FUNDRAISIDesc
Total$7,768TotalAmt
Fundraising$7,768FundraisingAmt

Total Functional Expenses TotalFunctionalExpensesGrp

FieldValueIRS element (for citing)
Total$29,717TotalAmt
Program Services$11,873ProgramServicesAmt
Management And General$0ManagementAndGeneralAmt
Fundraising$17,844FundraisingAmt

Savings And Temp Cash Invst SavingsAndTempCashInvstGrp

FieldValueIRS element (for citing)
BOY$1,090,645BOYAmt
EOY$1,111,821EOYAmt
FieldValueIRS element (for citing)
Land Bldg Equip Cost Or Other Bss$202,590LandBldgEquipCostOrOtherBssAmt
Land Bldg Equip Accum Deprec$61,570LandBldgEquipAccumDeprecAmt

Land Bldg Equip Basis Net LandBldgEquipBasisNetGrp

FieldValueIRS element (for citing)
BOY$144,027BOYAmt
EOY$141,020EOYAmt

Investments Pub Traded Sec InvestmentsPubTradedSecGrp

FieldValueIRS element (for citing)
BOY$503,302BOYAmt
EOY$606,800EOYAmt

Total Assets TotalAssetsGrp

FieldValueIRS element (for citing)
BOY$1,737,974BOYAmt
EOY$1,859,641EOYAmt

Accounts Payable Accr Expnss AccountsPayableAccrExpnssGrp

FieldValueIRS element (for citing)
BOY$2,300BOYAmt
EOY$0EOYAmt

Total Liabilities TotalLiabilitiesGrp

FieldValueIRS element (for citing)
BOY$2,300BOYAmt
EOY$0EOYAmt
FieldValueIRS element (for citing)
Organization Follows FASB117Yes (X)OrganizationFollowsFASB117Ind

No Donor Restriction Net Assets NoDonorRestrictionNetAssetsGrp

FieldValueIRS element (for citing)
BOY$1,482,252BOYAmt
EOY$1,612,177EOYAmt

Donor Restriction Net Assets DonorRestrictionNetAssetsGrp

FieldValueIRS element (for citing)
BOY$253,422BOYAmt
EOY$247,464EOYAmt

Total Net Assets Fund Balance TotalNetAssetsFundBalanceGrp

FieldValueIRS element (for citing)
BOY$1,735,674BOYAmt
EOY$1,859,641EOYAmt

Tot Liab Net Assets Fund Balance TotLiabNetAssetsFundBalanceGrp

FieldValueIRS element (for citing)
BOY$1,737,974BOYAmt
EOY$1,859,641EOYAmt
FieldValueIRS element (for citing)
Reconcilation Revenue Expnss$64,415ReconcilationRevenueExpnssAmt
Net Unrlzd Gains Losses Invst$59,552NetUnrlzdGainsLossesInvstAmt
Other Changes In Net Assets$0OtherChangesInNetAssetsAmt
Info In Schedule O Part XIIYes (X)InfoInScheduleOPartXIIInd
Method Of Accounting AccrualYes (X)MethodOfAccountingAccrualInd
Accountant Compile Or Review0AccountantCompileOrReviewInd
FS AuditedYes (1)FSAuditedInd

FS Audited Basis FSAuditedBasisGrp

FieldValueIRS element (for citing)
Consolidated Basis Fincl StmtYes (X)ConsolidatedBasisFinclStmtInd
FieldValueIRS element (for citing)
Audit CommitteeYes (1)AuditCommitteeInd
Federal Grant Audit Required0FederalGrantAuditRequiredInd

Schedule A IRS990ScheduleA

FieldValueIRS element (for citing)
Supporting Organization509a3Yes (X)SupportingOrganization509a3Ind
Supporting Org Type3 Func IntYes (X)SupportingOrgType3FuncIntInd
Supported Organizations1SupportedOrganizationsCnt

Supported Org Information SupportedOrgInformationGrp

Supported Organization Name SupportedOrganizationName

FieldValueIRS element (for citing)
Business Name Line1CHEYENNE COUNTY HOSPITAL ASSOCIATION INCBusinessNameLine1Txt
FieldValueIRS element (for citing)
EIN470408242EIN
Organization Type3OrganizationTypeCd
Governing Document ListedYes (1)GoverningDocumentListedInd
Support$0SupportAmt
Other Support$0OtherSupportAmt
FieldValueIRS element (for citing)
Supported Organizations Total1SupportedOrganizationsTotalCnt
Support Sum$0SupportSumAmt
Other Support Sum$0OtherSupportSumAmt

Form990 Sch A Supporting Org Form990SchASupportingOrgGrp

FieldValueIRS element (for citing)
Listed By Name Governing DocYes (1)ListedByNameGoverningDocInd
Suprt Org No IRS Determination0SuprtOrgNoIRSDeterminationInd
Supported Org Section C4560SupportedOrgSectionC456Ind
Supported Org Not Organized US0SupportedOrgNotOrganizedUSInd
Organization Change Suprt Org0OrganizationChangeSuprtOrgInd
Support Non Supported Org0SupportNonSupportedOrgInd
Payment Substantial Contribtr0PaymentSubstantialContribtrInd
Loan Disqualified Person0LoanDisqualifiedPersonInd
Controlled Disqualified Prsn0ControlledDisqualifiedPrsnInd
Disqualified Prsn Controll Int0DisqualifiedPrsnControllIntInd
Disqualified Prsn Ownr Int0DisqualifiedPrsnOwnrIntInd
Excess Business Holdings Rules0ExcessBusinessHoldingsRulesInd
Contribution Controller0ContributionControllerInd
Contribution Family0ContributionFamilyInd
Contribution35 Controlled0Contribution35ControlledInd

Form990 Sch A Type3 Sprt Org All Form990SchAType3SprtOrgAllGrp

FieldValueIRS element (for citing)
Timely Provided DocumentsYes (1)TimelyProvidedDocumentsInd
Officers Close RelationshipYes (1)OfficersCloseRelationshipInd
Supported Org Voice InvestmentYes (1)SupportedOrgVoiceInvestmentInd

Form990 Sch A Type3 Func Int Form990SchAType3FuncIntGrp

FieldValueIRS element (for citing)
Activities TestYes (X)ActivitiesTestInd
Activities Further Exempt PrpsYes (1)ActivitiesFurtherExemptPrpsInd
Activities Engaged Org InvlmntYes (1)ActivitiesEngagedOrgInvlmntInd

Form990 Schedule A Part VI Form990ScheduleAPartVIGrp (3 entries)

Form And Line ReferenceFormAndLineReferenceDescExplanationExplanationTxt
SECTION D, LINE 3:THE SUPPORTED ORGANIZATION, CHEYENNE COUNTY HOSPITAL ASSOCIATION, INC., APPOINTS 2 MEMBERS OF ITS BOARD OF DIRECTORS TO SIT ON THE BOARD OF DIRECTORS OF THE CHEYENNE COUNTY HOSPITAL AND HEALTH CENTER FOUNDATION. THESE DIRECTORS SERVE TO ASSIST IN THE DIRECTION OF THE FOUNDATION AND LEND A SIGNIFICANT VOICE TO ALL POLICIES AND PROCEDURES AND SERVE DURING THE ENTIRE YEAR. ADDITIONALLY, THE CFO OF THE CHEYENNE COUNTY HOSPITAL ASSOCIATION SERVES THE BOARD AS A FINANCIAL REPRESENTATIVE GIVING GUIDANCE TO THE BOARD AS NEEDED.
SECTION E, LINE 2A:THE PURPOSE OF THE ORGANIZATION IS TO SUPPORT THE CHEYENNE COUNTY HOSPITAL ASSOCIATION TO ASSURE THAT THERE IS AND ALWAYS WILL BE A STRONG FOUNDATION SUPPORTING HEALTH CARE IN CHEYENNE COUNTY. DURING 2021, THE FOUNDATION'S ACTIVITIES WERE FOCUSED ON THE SUPPORT OF THE HEALTHCARE MISSION AND INCREASING COMMUNITY AWARENESS OF THE FOUNDATION ITSELF. SIDNEY REGIONAL MEDICAL CENTER REQUESTED SUPPORT FROM THE FOUNDATION IN THE FORM OF FUNDING FOR EDUCATION AND SCHOLARSHIPS. THE FOUNDATION ALSO FUNDED AND HOSTED INTERNS WHO FURTHERED THEIR HEALTHCARE EDUCATION BY SHADOWING AND WORKING WITHIN THE HOSPITAL ORGANIZATION. MANY OF THESE INTERNS, AS WELL AS SCHOLARSHIP RECIPIENTS OF THE FOUNDATION, GO ON AND SUCCEED IN THEIR HEALTHCARE PROFESSIONS AND RETURN TO THE SIDNEY, NEBRASKA AREA AFTER THEIR TRAINING AND EDUCATION IS COMPLETE.
SECTION E, LINE 2B:IF THE FOUNDATION DIDN'T EXIST THERE WOULD STILL NEED TO BE A MECHANISM FOR ACCEPTING BEQUESTS AND OTHER GIFTS FROM PATIENTS, AS WELL AS FUNDRAISING FOR NEEDED EQUIPMENT AND FACILITIES IMPROVEMENTS. THE INTERN PROGRAM WOULD CONTINUE IN ORDER TO FURTHER THE RECRUITING EFFORTS BY THE HOSPITAL. THESE DEEPLY ROOTED EVENTS WOULD NEED TO CONTINUE TO BE HELD WITHIN THE COMMUNITY IN ORDER TO PROMOTE HEALTHY LIVING ACTIVITIES AND HOSPITAL COMMUNITY BENEFITS.

Schedule B IRS990ScheduleB

Contributor Information ContributorInformationGrp

FieldValueIRS element (for citing)
ContributorRESTRICTEDContributorNum

Contributor Business Name ContributorBusinessName

FieldValueIRS element (for citing)
Business Name Line1RESTRICTEDBusinessNameLine1

Contributor US Address ContributorUSAddress

FieldValueIRS element (for citing)
Address Line1RESTRICTEDAddressLine1
Address Line2RESTRICTEDAddressLine2
CityRESTRICTEDCity
StateRESTRICTEDState
ZIP CodeRESTRICTEDZIPCode
FieldValueIRS element (for citing)
Total ContributionsRESTRICTEDTotalContributionsAmt

Schedule D IRS990ScheduleD

Land LandGrp

FieldValueIRS element (for citing)
Other Cost Or Other Basis$126,483OtherCostOrOtherBasisAmt
Book Value$126,483BookValueAmt

Buildings BuildingsGrp

FieldValueIRS element (for citing)
Other Cost Or Other Basis$75,188OtherCostOrOtherBasisAmt
Depreciation$60,651DepreciationAmt
Book Value$14,537BookValueAmt

Equipment EquipmentGrp

FieldValueIRS element (for citing)
Other Cost Or Other Basis$919OtherCostOrOtherBasisAmt
Depreciation$919DepreciationAmt
Book Value$0BookValueAmt
FieldValueIRS element (for citing)
Total Book Value Land Buildings$141,020TotalBookValueLandBuildingsAmt
Footnote TextYes (X)FootnoteTextInd

Supplemental Information Detail SupplementalInformationDetail

FieldValueIRS element (for citing)
Form And Line ReferencePART X, LINE 2:FormAndLineReferenceDesc
ExplanationSRMC AND THE FOUNDATION ARE EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE INTERNAL REVENUE CODE AND A SIMILAR PROVISION OF STATE LAW. THE INTERNAL REVENUE SERVICE HAS ESTABLISHED STANDARDS TO BE MET TO MAINTAIN TAX-EXEMPT STATUS. THE ORGANIZATION ACCOUNTS FOR UNCERTAINTIES IN ACCOUNTING FOR INCOME TAX ASSETS AND LIABILITIES USING GUIDANCE INCLUDED IN FASB ASC 740, INCOME TAXES. THE ORGANIZATION RECOGNIZES THE EFFECT OF INCOME TAX POSITIONS ONLY IF THOSE POSITIONS ARE MORE LIKELY THAN NOT OF BEING SUSTAINED. AT DECEMBER 31, 2021, THE SYSTEM HAD NO UNCERTAIN TAX POSITIONS ACCRUED.ExplanationTxt

Schedule G IRS990ScheduleG

Fundraising Event Information FundraisingEventInformationGrp

FieldValueIRS element (for citing)
Event1GOLF TOURNAMENTEvent1Nm
Gross Receipts Event1$33,494GrossReceiptsEvent1Amt
Charitable Contri Event1$29,931CharitableContriEvent1Amt
Gross Revenue Event1$3,563GrossRevenueEvent1Amt
Rent Facility Costs Event1$1,391RentFacilityCostsEvent1Amt
Food And Beverage Event1$2,172FoodAndBeverageEvent1Amt
Other Direct Expenses Event1$66OtherDirectExpensesEvent1Amt
Gross Receipts Total$33,494GrossReceiptsTotalAmt
Charitable Contributions Tot$29,931CharitableContributionsTotAmt
Gross Revenue Total Events$3,563GrossRevenueTotalEventsAmt
Rent Fclty Costs Total Events$1,391RentFcltyCostsTotalEventsAmt
Food And Beverage Total Events$2,172FoodAndBeverageTotalEventsAmt
Oth Direct Expnss Total Events$66OthDirectExpnssTotalEventsAmt
Direct Expense Summary Events$3,629DirectExpenseSummaryEventsAmt
Net Income Summary-$66NetIncomeSummaryAmt

Schedule I IRS990ScheduleI

FieldValueIRS element (for citing)
Grant Records MaintainedYes (1)GrantRecordsMaintainedInd

Grants Other Asst To Indiv In US GrantsOtherAsstToIndivInUSGrp (2 entries)

Grant TypeGrantTypeTxtRecipientRecipientCntCash GrantCashGrantAmt
INTERN PROGRAM2$9,373
SCHOLARSHIP PROGRAM3$2,500

Supplemental Information Detail SupplementalInformationDetail

FieldValueIRS element (for citing)
Form And Line ReferencePART I, LINE 2:FormAndLineReferenceDesc
ExplanationTHE INTERNSHIP AND SCHOLARSHIP PROGRAM GRANTS LEARNING OPPORTUNITIES TO INDIVIDUALS IN THE AREA CURRENTLY STUDYING IN THE HEALTH CARE FIELD.ExplanationTxt

Schedule J IRS990ScheduleJ

FieldValueIRS element (for citing)
Severance Payment0SeverancePaymentInd
Supplemental Nonqual Rtr Plan0SupplementalNonqualRtrPlanInd
Equity Based Comp Arrngm0EquityBasedCompArrngmInd
Comp Based On Revenue Of Flng Org0CompBasedOnRevenueOfFlngOrgInd
Comp Bsd On Rev Related Orgs0CompBsdOnRevRelatedOrgsInd
Comp Bsd Net Earns Flng Org0CompBsdNetEarnsFlngOrgInd
Comp Bsd Net Earns Rltd Orgs0CompBsdNetEarnsRltdOrgsInd
Any Non Fixed Payments0AnyNonFixedPaymentsInd
Initial Contract Exception0InitialContractExceptionInd

Rltd Org Officer Trst Key Empl RltdOrgOfficerTrstKeyEmplGrp

FieldValueIRS element (for citing)
PersonKELLY UTLEYPersonNm
TitleEXECUTIVE DIRECTORTitleTxt
Base Compensation Filing Org$0BaseCompensationFilingOrgAmt
Compensation Based On Rltd Orgs$200,943CompensationBasedOnRltdOrgsAmt
Bonus Filing Organization$0BonusFilingOrganizationAmount
Bonus Related Organizations$2,500BonusRelatedOrganizationsAmt
Other Compensation Filing Org$0OtherCompensationFilingOrgAmt
Other Compensation Rltd Orgs$516OtherCompensationRltdOrgsAmt
Deferred Compensation Flng Org$0DeferredCompensationFlngOrgAmt
Deferred Comp Rltd Orgs$9,774DeferredCompRltdOrgsAmt
Nontaxable Benefits Filing Org$0NontaxableBenefitsFilingOrgAmt
Nontaxable Benefits Rltd Orgs$9,696NontaxableBenefitsRltdOrgsAmt
Total Compensation Filing Org$0TotalCompensationFilingOrgAmt
Total Compensation Rltd Orgs$223,429TotalCompensationRltdOrgsAmt
Comp Report Prior990 Filing Org$0CompReportPrior990FilingOrgAmt
Comp Report Prior990 Rltd Orgs$0CompReportPrior990RltdOrgsAmt

Supplemental Information Detail SupplementalInformationDetail

FieldValueIRS element (for citing)
Form And Line ReferencePART I, LINE 3FormAndLineReferenceDesc
ExplanationKELLY UTLEY, THE EXECUTIVE DIRECTOR OF THE FOUNDATION, IS AN EMPLOYEE OF CHEYENNE COUNTY HOSPITAL ASSOCIATION, D/B/A SIDNEY REGIONAL MEDICAL CENTER, A RELATED ENTITY. THE BOARD OF DIRECTORS OF THE MEDICAL CENTER REVIEWS MARKET COMPENSATION DATA FOR ALL HOSPITAL STAFF AND THE CEO OF THE MEDICAL CENTER APPROVES THE COMPENSATION FOR THE EXECUTIVE DIRECTOR.ExplanationTxt

Schedule O IRS990ScheduleO

Supplemental Information Detail SupplementalInformationDetail (4 entries)

Form And Line ReferenceFormAndLineReferenceDescExplanationExplanationTxt
FORM 990, PART VI, SECTION B, LINE 11BTHE FORM 990 INFORMATION IS ACCUMULATED BY THE ACCOUNTING DEPARTMENT AND SUBMITTED TO THE INDEPENDENT PUBLIC ACCOUNTANTS FOR FURTHER REVIEW AND PREPARATION. COMMUNICATIONS BETWEEN THE INDEPENDENT PUBLIC ACCOUNTANTS AND THE ACCOUNTING DEPARTMENT FINALIZE THE PREPARATION OF THE FORM 990. AFTER THE PREPARATION IS COMPLETE, THE EXECUTIVE DIRECTOR REVIEWS THE FORM 990. UPON APPROVAL, THE FORM 990 IS E-MAILED TO ALL MEMBERS OF THE BOARD OF DIRECTORS FOR THEIR REVIEW. ONCE THE FORM 990 HAS BEEN REVIEWED BY ALL PARTIES, IT WILL BE SUBMITTED TO THE IRS ON OR BEFORE THE EXTENDED DUE DATE.
FORM 990, PART VI, SECTION B, LINE 12CEACH YEAR, ALL BOARD MEMBERS ARE REQUIRED TO DISCLOSE ANY CONFLICTS OF INTEREST. ANY DUALITY OF INTEREST OR POTENTIAL CONFLICT OF INTEREST ON THE PART OF ANY OFFICER, DIRECTOR, COMMITTEE MEMBER, OR KEY EMPLOYEE IS REQUIRED TO BE DISCLOSED TO THE BOARD OF DIRECTORS AND MADE A MATTER OF BOARD RECORD WHENEVER IT ARISES, OR WHENEVER IT INVOLVES A MATTER OF BOARD ACTION. ANY OFFICER, DIRECTOR, COMMITTEE MEMBER, OR KEY EMPLOYEE HAVING A DUALITY OF INTEREST OR A POSSIBLE CONFLICT OF INTEREST IN ANY MATTER ABSTAINS FROM DISCUSSION AND THE VOTE.
FORM 990, PART VI, SECTION C, LINE 19THE FOUNDATION MAKES ITS GOVERNING DOCUMENTS AND FINANCIAL STATEMENTS, BUT NOT ITS CONFLICY OF INTEREST POLICY, AVAILABLE TO THE PUBLIC UPON REQUEST.
FORM 990, PART VI, SECTION B, LINE 15:AS THE ORGANIZATION DOES NOT HAVE ANY EMPLOYEES, THERE IS NO INDEPENDENT REVIEW AND APPROVAL OF COMPENSATION.

Schedule R IRS990ScheduleR

Id Related Tax Exempt Org IdRelatedTaxExemptOrgGrp

Disregarded Entity Name DisregardedEntityName

FieldValueIRS element (for citing)
Business Name Line1CHEYENNE COUNTY HOSPITAL ASSOCIATION INCBusinessNameLine1Txt

US Address USAddress

FieldValueIRS element (for citing)
Address Line11000 POLE CREEK CROSSINGAddressLine1Txt
CitySIDNEYCityNm
State AbbreviationNEStateAbbreviationCd
ZIP69162ZIPCd
FieldValueIRS element (for citing)
EIN470408242EIN
Primary ActivitiesPROVIDING HEALTH CARE TO THOSE IN THE COMMUNITYPrimaryActivitiesTxt
Legal Domicile StateNELegalDomicileStateCd
Exempt Code Section501(C)(3)ExemptCodeSectionTxt
Public Charity StatusLINE 3PublicCharityStatusTxt
Direct Controlling NAN/ADirectControllingNACd
Controlled Organization0ControlledOrganizationInd
FieldValueIRS element (for citing)
Receipt Of Int Annts Rnts Rylts0ReceiptOfIntAnntsRntsRyltsInd
Gift Grnt Or Cap Contri To Oth Org0GiftGrntOrCapContriToOthOrgInd
Gift Grnt Cap Contri From Oth OrgYes (1)GiftGrntCapContriFromOthOrgInd
Loans Or Guarantees To Other Org0LoansOrGuaranteesToOtherOrgInd
Loans Or Guarantees From Oth Org0LoansOrGuaranteesFromOthOrgInd
Div Related Organization0DivRelatedOrganizationInd
Asset Sale To Other Org0AssetSaleToOtherOrgInd
Asset Purchase From Other Org0AssetPurchaseFromOtherOrgInd
Asset Exchange0AssetExchangeInd
Rental Of Facilities To Oth Org0RentalOfFacilitiesToOthOrgInd
Rental Of Fclts From Oth Org0RentalOfFcltsFromOthOrgInd
Perform Of Services For Oth OrgYes (1)PerformOfServicesForOthOrgInd
Perform Of Services By Other Org0PerformOfServicesByOtherOrgInd
Sharing Of FacilitiesYes (1)SharingOfFacilitiesInd
Paid Employees SharingYes (1)PaidEmployeesSharingInd
Reimbursement Paid To Other OrgYes (1)ReimbursementPaidToOtherOrgInd
Reimbursement Paid By Other OrgYes (1)ReimbursementPaidByOtherOrgInd
Transfer To Other Org0TransferToOtherOrgInd
Transfer From Other Org0TransferFromOtherOrgInd

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